Frequently Asked Questions

The Affordable Care Act (ACA) Marketplace – also called the Health Insurance Marketplace or "Obamacare" – offers health insurance plans for people who don't have coverage through Medicare, Medicaid, or an employer.

Key features:

• Coverage for essential health benefits (hospitalization, prescriptions, maternity, mental health, etc.)
• No denial for pre-existing conditions
• Premium tax credits available based on income
• Metal tier plans: Bronze, Silver, Gold, Platinum

ACA plans are available to most people under 65 who aren't eligible for Medicare. Once you turn 65, you'll generally transition to Medicare.

Here's a summary of the key Medicare costs for 2026:

Remember: These are baseline costs. Your actual costs depend on your coverage choices, health needs, and income level. We can help you find the most cost-effective combination for your situation.

The Annual Enrollment Period runs from October 15 to December 7 each year. Any changes you make take effect January 1.

During AEP, you can:

• Switch from Original Medicare to Medicare Advantage (or vice versa)
• Change from one Medicare Advantage plan to another
• Join a Medicare Part D prescription drug plan
• Switch from one Part D plan to another
• Drop Part D coverage (not usually recommended)

This is the most important time of year to review your coverage. Drug costs and plan benefits change annually, so even if you're happy with your current plan, it's worth comparing options.

Your Initial Enrollment Period (IEP) is a 7-month window centered around your 65th birthday:

• Starts 3 months before your 65th birthday month
• Includes your birthday month
• Ends 3 months after your birthday month

Important tip: If your birthday is on the 1st of the month, your IEP starts one month earlier. For coverage to begin on your birthday, enroll during the first 3 months of your IEP.

Missing your IEP can result in permanent late enrollment penalties, so it's important to plan ahead. Contact us 2-3 months before turning 65 to review your options.

Medicare is the federal health insurance program for people 65 and older, as well as certain younger individuals with disabilities or End-Stage Renal Disease (ESRD).

You're automatically eligible for Medicare if you:

• Are 65 or older and a U.S. citizen or permanent legal resident for at least 5 years
• Have received Social Security Disability benefits for 25 months
• Have ALS (Lou Gehrig's disease) or End-Stage Renal Disease

Most people don't pay a premium for Part A if they or their spouse worked and paid Medicare taxes for at least 10 years (40 quarters).

Medicare and Medicaid are both government health insurance programs, but they serve different populations and work very differently. Here's a quick comparison:

Medicare

• Federal program — same rules nationwide
• Primarily for people 65 and older, or those with certain disabilities
• Has premiums, deductibles, and copays
• Parts A (hospital), B (medical), C (Advantage), and D (prescriptions)

Medicaid (BadgerCare Plus in Wisconsin)

• Joint federal and state program — rules vary by state
• Based on income, not age — available to qualifying individuals of any age
• Little to no cost for eligible individuals

Can you have both? Yes — some people qualify for both Medicare and Medicaid ("dual eligible"). Special Dual-Eligible Special Needs Plans (D-SNPs) coordinate benefits from both programs.

Thiel & Associates specializes in Medicare — including Medicare Advantage, Medicare Supplements, and Part D prescription drug plans. For Medicaid and BadgerCare Plus questions, contact the Wisconsin Department of Health Services at 1-800-362-3002 or visit ForwardHealth.wi.gov.

This is one of the most important decisions you'll make when enrolling in Medicare. Here's how they compare:

Original Medicare (Parts A & B) is administered by the federal government. You can see any doctor or hospital that accepts Medicare nationwide. There's no network, but you'll typically pay 20% coinsurance with no annual out-of-pocket maximum.

Medicare Advantage (Part C) plans are offered by private insurance companies. They must cover everything Original Medicare covers, but most add extra benefits like dental, vision, hearing, and fitness programs. Plans have networks and annual out-of-pocket maximums for protection.

Many people in Wisconsin choose Medicare Advantage for the extra benefits and cost predictability, while others prefer Original Medicare's flexibility paired with a Medigap supplement plan.

It depends on your coverage. If you have Original Medicare with a Medigap plan, you will need a standalone Part D prescription drug plan. If you have a Medicare Advantage plan (MAPD), prescription drug coverage is typically included. We can help you determine whether you need separate drug coverage based on your situation.

Medicare Part A is Hospital Insurance that covers:

• Inpatient hospital care – Room, meals, nursing care, medications, and other hospital services
• Skilled nursing facility (SNF) care – Up to 100 days per benefit period following a qualifying 3-day hospital stay
• Hospice care – Comfort care for terminal illness, including medications for pain relief
• Home health care – Intermittent skilled nursing and therapy services if you're homebound

Note: Part A does not cover long-term (custodial) care, such as help with daily living activities in a nursing home.

No – our services are completely free to you.

Here's how it works: Insurance companies pay agents a commission for helping people enroll in their plans. This commission is built into the plan's pricing, so you pay the same premium whether you go direct or work with an agent.

The difference is that when you work with us, you get:

• Expert guidance in choosing the right plan
• Help understanding your options
• Someone to call when you have questions
• Annual plan reviews to make sure you're still in the best plan

There's no catch, no pressure, and no obligation. We're here to help.

Medicare Advantage (Part C) is an alternative way to receive your Medicare benefits through private insurance companies approved by Medicare.

How it works:

1. You still pay your Part B premium ($202.90/month in 2026)
2. Your plan covers everything Original Medicare covers
3. Most plans add extra benefits (dental, vision, hearing, fitness)
4. Many plans include Part D drug coverage
5. Plans have an annual out-of-pocket maximum for protection

In 2026, about 60% of Medicare Advantage plans have $0 monthly premiums. You only pay your Part B premium and any copays when you use services.

Medicare Supplement (Medigap) is private insurance that helps pay for costs that Original Medicare doesn't fully cover — like deductibles, copays, and coinsurance.

How Wisconsin Is Different

Wisconsin is one of only three states (along with Minnesota and Massachusetts) with its own Medigap system. While 47 states use standardized lettered plans (Plan A, G, N, etc.), Wisconsin uses a Basic Plan with optional riders that let you customize your coverage.

Key things to know:

• Works alongside Original Medicare — not a replacement. You must have Parts A and B to enroll.
• Every insurer must offer the Basic Plan, which covers Part B coinsurance (the 20% Medicare doesn't pay), 365 extra hospital days, blood costs, and Wisconsin state-mandated benefits like diabetic supplies and chiropractic care.
• You add optional riders to build the coverage you need — like the Part A Deductible rider ($1,736 in 2026), Part B Excess Charges rider, Foreign Travel Emergency, and more.
• Premiums vary significantly between carriers for identical coverage, so comparison shopping is essential. That's where we come in.

Because Wisconsin's system is unique, national Medicare advice about "Plan G" or "Plan N" doesn't directly apply here. We specialize in helping Wisconsin residents navigate the Basic Plan and rider options to find the right fit.

Medicare Part D is prescription drug coverage offered through private insurance companies approved by Medicare.

You can get Part D coverage two ways:

1. Standalone Prescription Drug Plan (PDP) – Adds drug coverage to Original Medicare or Medigap
2. Medicare Advantage with drug coverage (MA-PD) – Bundled into your Medicare Advantage plan

Each plan has a formulary (list of covered drugs) organized into tiers. Generic drugs are usually in lower tiers with smaller copays, while brand-name and specialty drugs are in higher tiers.

The average standalone Part D premium in 2026 is $34.50/month.

Medicare is divided into four distinct parts, each covering different services:

Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most people get Part A premium-free.

Part B (Medical Insurance) covers doctor visits, outpatient care, preventive services, lab tests, and durable medical equipment. The 2026 standard premium is $202.90/month.

Part C (Medicare Advantage) is an alternative to Original Medicare offered by private insurers. These plans combine Parts A, B, and usually D, often with extra benefits like dental and vision.

Part D (Prescription Drug Coverage) helps pay for prescription medications. You can get Part D through a standalone plan or a Medicare Advantage plan that includes drug coverage.

Medicare Part B is Medical Insurance that covers two main categories:

Medically Necessary Services

• Doctor and specialist visits
• Outpatient hospital services and surgeries
• Lab tests, X-rays, and diagnostic imaging
• Mental health services (inpatient and outpatient)
• Durable medical equipment (wheelchairs, walkers, oxygen)
• Ambulance services when medically necessary

Preventive Services (usually at no cost)

• Annual Wellness Visit and "Welcome to Medicare" visit
• Flu, pneumonia, COVID-19, and hepatitis B vaccines
• Mammograms, colonoscopies, and other cancer screenings
• Cardiovascular and diabetes screenings

Most people pay $0 for Part A premiums if they or their spouse worked and paid Medicare taxes for at least 10 years (40 quarters).

If you don't qualify for premium-free Part A:

• 30-39 quarters of work: $311/month
• Fewer than 30 quarters: $565/month

2026 Part A Deductibles and Coinsurance:

The standard Part B premium for 2026 is $202.90 per month. The annual deductible is $283.

After meeting your deductible, you typically pay 20% coinsurance for most Part B services.

Higher earners pay more due to IRMAA (Income-Related Monthly Adjustment Amount). This is based on your tax return from 2 years ago:

If your income has dropped due to a life-changing event (retirement, divorce, death of spouse), you can request a reduction using Form SSA-44.

A benefit period begins the day you're admitted as an inpatient and ends when you haven't received inpatient care for 60 consecutive days.

Why this matters:

• You pay the Part A deductible ($1,736 in 2026) once per benefit period, not once per year
• If you're hospitalized, go home, then return within 60 days, it's the same benefit period
• If 60+ days pass before readmission, a new benefit period starts and you pay the deductible again

There's no limit to how many benefit periods you can have. This is why many people add a Medicare Supplement (Medigap) plan – it can cover these deductibles and coinsurance amounts.

The Medicare Advantage Open Enrollment Period (MA OEP) runs from January 1 to March 31 each year.

This period is only for people currently enrolled in a Medicare Advantage plan. During MA OEP, you can:

• Switch to a different Medicare Advantage plan
• Return to Original Medicare and join a standalone Part D plan

You can only make one plan change during this period. If you're on Original Medicare with a Medigap plan, this period doesn't apply to you.

Changes take effect the first of the month after your enrollment is processed.

Medicare Advantage plans often include benefits that Original Medicare doesn't cover:

Common Extra Benefits

• Dental care – Routine cleanings, X-rays, fillings, and sometimes major work
• Vision coverage – Eye exams and allowances for glasses/contacts
• Hearing benefits – Hearing exams and discounts on hearing aids
• Fitness programs – Gym memberships like SilverSneakers
• Over-the-counter allowances – Quarterly credits for OTC health items
• Transportation – Rides to medical appointments
• Meal delivery – Meals after hospital stays or for chronic conditions

Benefits vary by plan, so it's important to compare options available in your area. We can help you find plans with the benefits that matter most to you.

Since Wisconsin uses its own Medigap system (Basic Plan + riders instead of lettered plans), the most popular combinations depend on your needs and budget. Here are the three most common:

Most Comprehensive (similar to Plan G in other states)

Basic Plan + Part A Deductible + Part B Excess Charges + Foreign Travel Emergency + Additional Home Health Care. This is the most popular choice for new enrollees. Your only regular out-of-pocket cost is the annual Part B deductible ($283 in 2026). Everything else is covered.

Budget-Friendly (similar to Plan N in other states)

Basic Plan + Part A Deductible + Part B Copayment/Coinsurance Rider + Foreign Travel Emergency. You accept $20 office visit and $50 ER copays in exchange for lower monthly premiums. A good option if you're generally healthy and want to save on premiums.

Full Coverage (Pre-2020 enrollees only)

Basic Plan + Part A Deductible + Part B Deductible + Part B Excess Charges + Foreign Travel Emergency + Additional Home Health Care. True first-dollar coverage — virtually zero out-of-pocket costs. Only available if you became Medicare-eligible before January 1, 2020.

How to choose

Because Wisconsin lets you mix and match riders, you can build exactly the coverage you want rather than choosing from a fixed menu. Premiums for identical coverage can vary by $100/month or more between carriers, so comparing is critical. We'll show you all the options side by side.

The Inflation Reduction Act brought major improvements to Part D that continue in 2026:

Out-of-Pocket Cap

Your drug costs are now capped at $2,000/year. Previously, there was no cap and some people paid $10,000+ annually.

$35 Insulin Cap

Insulin costs are capped at $35 per month for covered insulin products.

Free Vaccines

All recommended vaccines are now covered at $0 cost, including shingles (Shingrix).

Medicare Prescription Payment Plan

You can spread your drug costs into monthly payments throughout the year – no interest or fees.

The main difference is how you access care and whether you can see out-of-network providers:

In Wisconsin, we have strong networks for both HMO and PPO plans. If you travel frequently or have doctors outside your local area, a PPO may give you more flexibility.

The best time is during your Medigap Open Enrollment Period — the 6-month window that starts the month you turn 65 AND are enrolled in Medicare Part B.

Why this window matters:

• Guaranteed issue: Insurance companies cannot deny you coverage for any reason.
• No health screening: They cannot charge more due to pre-existing conditions or health history.
• Full rider access: You can purchase any combination of riders you want.
• 30-day free look: All Wisconsin Medigap policies include a 30-day free-look period — you can return the policy for a full refund if it's not right for you.

After your open enrollment window:

Insurers may use medical underwriting — they can ask health questions, deny coverage, or charge higher premiums. Pre-existing condition waiting periods of up to 6 months may apply. This is why enrolling during your initial window is so important.

Guaranteed issue rights (outside open enrollment)

You can still get coverage without underwriting if you experience certain qualifying events — like losing employer coverage, your plan leaving your area, or returning to Original Medicare from Medicare Advantage within 12 months. You have 63 days from the event to apply.

Under 65 with Medicare?

Wisconsin requires insurers to sell Medigap to disabled Medicare beneficiaries under 65 during their open enrollment window — a protection that many states don't offer. You'll also get a second open enrollment window when you turn 65.

The "donut hole" (coverage gap) was a phase of Part D where you paid a larger share of drug costs. Good news: it's been eliminated.

Here's how Part D works in 2026:

The old 4-phase system with a coverage gap is gone. Now you simply pay your share until you hit the $2,100 cap, then pay nothing for the rest of the year.

Yes, you have several opportunities to switch:

Medicare Advantage Open Enrollment (Jan 1 – Mar 31): If you're in a Medicare Advantage plan, you can switch to a different MA plan or return to Original Medicare (and add a Part D plan). Changes take effect the 1st of the following month.

Annual Enrollment Period (Oct 15 – Dec 7): You can switch between Original Medicare and Medicare Advantage, or change plans. Coverage begins January 1.

Important: If you switch back to Original Medicare and want a Medigap supplement plan, you may need to go through medical underwriting unless you have guaranteed issue rights. In Wisconsin, we have some of the strongest Medigap protections in the country.

Yes! Wisconsin has some of the strongest Medigap consumer protections in the country, plus a completely different plan structure from most states.

Unique plan structure

• Basic Plan + riders instead of lettered plans. Wisconsin doesn't use Plan G, Plan N, etc. — you start with a Basic Plan and add riders to customize your coverage.
• 7 optional riders available: Part A Deductible, 50% Part A Deductible, Part B Deductible (pre-2020 only), Part B Excess Charges, Additional Home Health Care, Foreign Travel Emergency, and Part B Copayment/Coinsurance.

Consumer protections

• 6-month guaranteed issue window when you turn 65 and enroll in Part B — no health questions, no denials, no higher premiums based on health.
• Under-65 access — Wisconsin requires insurers to sell Medigap to disabled Medicare beneficiaries, which many states don't.
• State-mandated benefits built into the Basic Plan that go beyond federal minimums: kidney disease treatment (up to $30,000/year), diabetic supplies, chiropractic care, and colorectal cancer screening.
• 30-day free-look period on all Medigap policies — return for a full refund if not satisfied.

Important notes

• No birthday rule: Unlike some states (Oregon, California, Illinois), Wisconsin does not currently allow annual Medigap switching without medical underwriting around your birthday.
• Premium variation: Carriers can use attained-age, issue-age, or community rating. Premiums for identical coverage can differ dramatically between carriers — comparison shopping saves real money.

For the official list of approved Medigap policies and premium comparisons, check the Wisconsin OCI (Office of the Commissioner of Insurance) guide at oci.wi.gov, or give us a call and we'll walk you through it.

If you go 63 days or longer without Part D or other creditable drug coverage, you may face a permanent late enrollment penalty.

How it's calculated:

• 1% of the national base premium ($38.99 in 2026) × number of months without coverage
• This amount is added to your monthly Part D premium for life

Example: If you went 24 months without coverage, your penalty would be about $9.36/month added to your premium permanently.

You won't pay a penalty if you had "creditable" drug coverage – coverage that's expected to pay at least as much as standard Part D. Employer plans and VA coverage typically qualify.

IRMAA (Income-Related Monthly Adjustment Amount) is an extra amount higher-income beneficiaries pay for Part B and Part D coverage.

IRMAA is based on your tax return from 2 years ago. For 2026 premiums, Social Security looks at your 2024 income.

For married couples filing jointly, the thresholds are doubled.

If your income dropped due to a life-changing event (retirement, death of spouse, divorce, job loss), you can request a reduction by filing Form SSA-44 with Social Security.

Extra Help (also called the Low Income Subsidy or LIS) is a federal program that helps pay Part D costs for people with limited income and resources.

2026 Eligibility (approximate):

• Income: Up to $2,015/month (single) or $2,725/month (couple)
• Resources: Up to $16,590 (single) or $33,100 (couple) – not counting your home

With Extra Help, you could get:

• $0 Part D premium
• $0 deductible
• Copays capped at $5.10 (generic) or $12.65 (brand name)

You're automatically eligible if you have Medicaid, receive SSI, or qualify for a Medicare Savings Program. Otherwise, you can apply through Social Security.

Special Enrollment Periods let you make changes outside the normal enrollment windows when you experience certain life events.

Common SEP triggers include:

• Losing employer or union health coverage
• Moving out of your plan's service area
• Your plan terminates or loses its Medicare contract
• Qualifying for Medicaid or Extra Help (Low Income Subsidy)
• Moving into or out of a nursing home
• Being released from incarceration

SEPs typically last 2-3 months depending on the qualifying event. If you think you may qualify for a SEP, contact us to review your options.

If you miss your Initial Enrollment Period and don't have qualifying coverage, you may have to wait to enroll and pay penalties.

General Enrollment Period (GEP): January 1 – March 31 each year. If you enroll during GEP, your coverage won't start until July 1.

Late enrollment penalties:

• Part B: 10% premium increase for each 12-month period you could have enrolled but didn't (permanent)
• Part D: 1% of the national base premium per month without creditable coverage (permanent)

The exception: If you have creditable coverage through an employer (with 20+ employees), you won't face penalties when you enroll later through a Special Enrollment Period.

It depends on your employer's size and your current coverage:

Employer with 20+ employees: Your employer coverage is "primary" (pays first). You can delay Medicare Part B without penalty while you have this coverage. However, you may want to enroll in premium-free Part A.

Employer with fewer than 20 employees: Medicare becomes your primary coverage. You should enroll in both Parts A and B during your IEP to avoid gaps and penalties.

When you retire or lose employer coverage, you'll have an 8-month Special Enrollment Period to sign up for Medicare without penalties.

For most states, ACA Open Enrollment for 2026 coverage runs from November 1, 2025 to January 15, 2026.

To have coverage start January 1, you need to enroll by December 15. If you enroll after that date, coverage begins February 1.

Some states have extended deadlines. Check with us or healthcare.gov for your state's specific dates.

Outside of Open Enrollment, you may qualify for a Special Enrollment Period if you:

• Lose other health coverage
• Get married or have a baby
• Move to a new area
• Have a change in income affecting subsidy eligibility

Important SEP Timeframes

• 60-day window: You generally have 60 days from the qualifying event to enroll in a new plan.
• Loss of coverage: If you're losing existing coverage, your SEP starts 60 days before the coverage end date, giving you time to line up new coverage in advance.
• 2026 change: Year-round enrollment based on income alone ended after 2025. For 2026, you must have a qualifying life event and provide documentation to enroll outside of Open Enrollment.

Important: The enhanced premium tax credits from the Inflation Reduction Act expired at the end of 2025.

What this means for 2026:

• The "subsidy cliff" has returned – people over 400% of the Federal Poverty Level may no longer qualify for subsidies
• Premium increases estimated at 20–30% nationally
• If you over-estimated income and received too much in subsidies, you must repay the excess

If you're currently on an ACA plan, it's critical to review your options during Open Enrollment. Your costs may have changed significantly. Contact us for a free review of your 2026 options.

Outside of Open Enrollment (November 1 – January 15), you can only enroll in an ACA Marketplace plan if you experience a qualifying life event (QLE). Here are the most common events that trigger a Special Enrollment Period:

Loss of Coverage

• Losing job-based health insurance (layoff, reduction in hours, job change)
• Aging off a parent's plan at 26
• COBRA coverage expiring
• Losing Medicaid or BadgerCare Plus eligibility
• Divorce or legal separation causing loss of coverage

Life Changes

• Getting married
• Having a baby, adopting a child, or foster care placement
• Permanent move to a new area with different plan options
• Gaining U.S. citizenship or lawful immigration status

Other Triggers

• Income change that affects subsidy eligibility
• Employer plan becomes unaffordable (exceeds ~9.12% of household income)
• Enrollment error by the Marketplace or an assister

How long do you have?

• 60 days from most qualifying events to enroll in a new plan.
• Loss of coverage: Your SEP starts 60 days before the coverage end date, so you can line up new coverage in advance.
• Loss of Medicaid/BadgerCare: 90 days from the date coverage ends.
• Birth or adoption: Coverage can be backdated to the date of the event.

What changed for 2026

Year-round enrollment based on low income ended in August 2025. For 2026, you must have a qualifying life event to enroll outside of Open Enrollment — even if your income is below 150% of the Federal Poverty Level. The enhanced ACA subsidies also expired at the end of 2025, which means higher premiums for many consumers. Contact us to review your options.

Not sure if your situation qualifies? Give us a call — we can help determine your eligibility and walk you through the enrollment process.

Working with a local independent agent like Thiel & Associates gives you several advantages:

• Personalized guidance – We meet with you one-on-one to understand your specific needs, health situation, and budget
• Unbiased comparisons – We work with multiple insurance carriers, so we can show you all your options, not just one company's plans
• Local expertise – We know the Wisconsin market, local doctors, and which plans work best in our area
• Year-round support – We're here to help with claims issues, billing questions, and plan changes throughout the year
• No extra cost – Our services are free to you. Insurance companies pay us, and prices are the same whether you use an agent or not

We've helped thousands of people in Shawano and the surrounding area find the right coverage. We'd love to help you too.

Getting started is easy:

1. Request a free quote – Fill out our simple online form or give us a call
2. Schedule a consultation – We'll set up a time to meet (in person, by phone, or video)
3. Review your options – We'll explain your choices in plain English and answer your questions
4. Enroll with confidence – Once you choose a plan, we handle the paperwork

The whole process is simple and stress-free. We're patient, we don't use confusing jargon, and we never pressure you into a decision.

We're based in Shawano County, Wisconsin and serve clients across the entire state of Wisconsin. Whether you're in the next county or across the state, you get the same personal service.

Counties we commonly serve:

• Shawano, Waupaca, and Outagamie Counties
• Brown, Oconto, and Marinette Counties
• Winnebago, Calumet, and Fond du Lac Counties
• Marathon, Portage, and Wood Counties
• Door, Kewaunee, and Manitowoc Counties
• Langlade, Menominee, and Lincoln Counties

Don't see your county? No problem — we serve clients across all 72 Wisconsin counties. Most of our consultations can be done by phone or video, so distance is never an issue. Give us a call or request a quote online and we'll take care of you.

To make the most of your consultation, please have the following ready:

• Your Medicare card (if you have one)
• List of your current medications (including dosages)
• Names of your doctors and any preferred hospitals or clinics
• Information about any current health coverage you have
• Questions or concerns you'd like to discuss

Don't worry if you don't have everything – we can still help. We're happy to work with whatever information you have available.